KATV: Dr. Muhammad Waqas Discusses Pulmonary Hypertension

KATV: Dr. Muhammad Waqas Discusses Pulmonary Hypertension

October 19, 2019 0 By Bertrand Dibbert


Welcome. I’m Beth Hunt in the KATV
studios. Thanks for watching tonight. This is the third in a series of webcasts
focused on your health that KATV is producing in partnership with CHI St. Vincent. I’m joined tonight by Dr. Muhammad Waqas, cardiologist with CHI St. Vincent Heart Institute and over the next
half hour we’ll be focusing on pulmonary hypertension. We’d like to answer any
questions that you may have, so we invite you to submit them right here in the
comments section of this web stream. We’ll answer your questions as we get them. In
the meantime Dr. Waqas, thanks for being with us. Thank you for having me. We
appreciate you being here with us for the next thirty minutes. You work closely
with patients who suffer from pulmonary hypertension. What is that and how is it
different from regular hypertension? The word pulmonary means lungs and
hypertension means high blood pressure and so the word pulmonary hypertension
generally means high lung pressure in lung circulation system. So
if we put cuff on our arm to check our blood pressure normally as we go to the
doctor and we are told that we have blood pressure 120 over 80 as a normal
blood pressure. Similarly lung blood pressure has a
certain number and if that number goes beyond the normal number then we call it
high lung pressure and which is pulmonary hypertension. How common is
this here in Arkansas? Well I think the incidence of the disease is a lot more
than what we have seen so far. That is purely because we don’t
think about this disease as much or use not to at least and now that we are
thinking about and diagnosing the disease a lot more the incidence has gone up. It
used to be called more of a rare disease but it’s not rare. Iit’s more
uncommon than being rare and now that we patients and physicians are thinking
about this disease a lot more we are seeing it more commonly. Do we know what
causes it or how it develops? Since 1973 we have a lot of work done
in the field of pulmonary hypertension and we had World Health symposiums on
pulmonary hypertension going on since 1973 starting from Geneva and we have
categorized this disease into different categories based on
where it is originating from and what it is affecting. There are
different clinical conditions which can be lumped into one category. Overall
World Health Organization has categorized into five distinct groups
and those groups are primarily based on where the primary disease can be. For
example it could be lung itself which can cause pulmonary hypertension. It can
be from left heart disease. It can be from chronic thrombus disease. In some
patient is idiopathic or unknown etiology. In some patient it is caused
from hereditary transmission of disease and there’s so many other conditions
including infections which push patient higher risk for developing
pulmonary hypertension. What are some of the symptoms of this? So that is what the
most I shouldn’t say puzzling but the common
condition or symptoms with this condition are shortness of breath,
fatigue, being tired most of the time, chest pain, and especially with the
exertion the diseased will become very short of breath and fatigued. Now because heart and
lung work together, these symptoms often can be masked by other lung
conditions or any other heart condition and that is why common practitioners
when they when they see these symptoms we normally and actually truly
should think of heart and lung as a first culprit but then we’re going dig
in more deeper we can we find that patient has pulmonary hypertension. So the
symptoms can be similar symptoms that any lung or heart condition can can cause
which is shortness of breath and fatigue and being tired, leg swelling and as the
disease advances these symptoms can get worse. They become more prominent and
more advanced. Is this something that is hard to detect or or is it something
that often goes undetected in someone? I think the latter. it goes
undetected for a longer time and what we have seen in different registries is that
over the time it takes from the symptom onset through diagnosis on average can
be anywhere from two to three years. So, sometimes it can lag even more than
three years. So, depending on the the suspicion of the disease the
symptoms from symptom onset to diagnosis can be delayed anywhere from two to
three years. Also, I think it is because we are not used to seeing
this very commonly and not diagnosing it on time either. We talked a little
bit about the symptoms, let’s talk about risk factors is there anything that
makes someone where it would be more possible for them to be diagnosed with
this? So, like I said earlier, because the disease has been categorized into five
distinct classes of clinical classes each class has its own risk factor. For
example, patients with left heart disease or patients with low heart function or
congestive heart failure patients with stiff heart, patients with bad valvular
heart disease, patients with bad rhythm issues and patients with COPD, asthma
patient with chronic hepatitis infection, patients with chronic DVTs, or deep
venous thrombosis in their lungs, patients with bad kidney diseases all of
them these conditions for them high risk for developing pulmonary hypertension. On
top of that in simple obesity for example is another risk factor for
pulmonary hypertension over long term and chronic lung condition. Chronic lung
condition can also be a risk factor. So, all these conditions together or
separately can put a patient at risk for pulmonary hypertension. We’re already starting to get some questions online so I’m going to break
away from mine for a moment and address some of those. Donna Weeks wants to know,
does pulmonary hypertension ever go away? So you know there is one condition which
is curative. Once patients are diagnosed with pulmonary hypertension, just like any
other condition like diabetes, we can we can treat it and make it stable and
control the severity of it. Similarly, in pulmonary hypertension we can control
the severity of the condition. In one type of pulmonary hypertension which is
from chronic shoveling of clots in the lungs that can be completely cured. In
certain developing countries only certain infections if they are cured
pulmonary hypertension can go away. But there are only few conditions where it can be
completely cured. In other cases, which is majority of the
cases, we treat risk factors and the severity of the
condition gets better. All right and is this something that is difficult to
diagnose are there any certain tests that you all use to diagnose it and
also determine how severe it is in a patient? So, when a patient presents with
symptoms of one we have mentioned such as shortness of breath which is being
the most common symptom, we look for different conditions. We look for heart
and lung conditions in general and one of the tests that we do, which is the most
common screening factor or screening test, for pulmonary hypertension is an
echocardiogram which is the ultrasound of the heart. That looks at different
parts of the heart different chambers and and we can look at and estimate the
pressure on the right side of the heart and if that side has higher lung pressure, we can do the invasive test which is the diagnostic or
confirmation test. So, initially echocardiogram is the most common
screening test and the heart catheterization also known as right
heart catheterization is the diagnostic test for pulmonary hypertension. What is
life like for a patient who has pulmonary hypertension? You know, most of
the time when patients come in and they especially when they are being referred
by a physician, if between the referral and when they see me they have
Google most of the time what pulmonary hypertension is and quite a few times
patients come and ask me hey doc I looked at Google and I was told that I have
only a few more months to live since I’ve been diagnosed with this condition. So, that is actually a misconception. Now, based on the type of pulmonary
hypertension, the longevity of a patient can be different and there are some more
severe and serious forms of pulmonary hypertension and some other forms are not as
severe. Yet, once the diagnosis of pulmonary hypertension is established, of course
life is not exactly as as it would be without pulmonary hypertension and the
severe more severe the disease is the expectant life expectancy can go lower.
That is why we want to diagnose the disease earlier, so we can treat it on
time, so they improve quality of life but also increased more
years to someone’s life. If this goes undiagnosed, I would imagine it would
lead to other complications. What are some of those things that could happen?
Absolutely, so we have two main chambers of our heart, right and left. The
right heart pumps blood into lungs from lungs it goes to the left side. Left side
pumps it back to the body and comes back to the right heart. The right heart as it is
pumping into lungs, if the lung pressures are high, the right heart starts to
struggle. Over time, the right heart can start failing and can lead to more
complications such as the swelling of legs, swelling of belly, loss of
appetite and then eventually if the heart gets stretched too much the right
heart can fail or stop. Now that is where the advanced disease term comes in
to — conditions can lead to advance right heart failure.
We know that there are treatment options and we have someone on our
Facebook page who has asked if you’ve seen results any good results with the
current medications that are out there today.
Well, absolutely, again the treatment strategy about pulmonary hypertension clearly
depends on the type of pulmonary hypertension. There are multiple
examples of different conditions and different risk factors which can lead to
different diagnosis. For example the most common treatable cause of pulmonary
hypertension is to treat its risk. Patients with bad congestive heart
failure, if we treat their heart failure the pulmonary hypertension gets better.
Similarly if we treat certain lung conditions such as sleep apnea pulmonary hypertension will get better. Now, there’s another subset of a little
uncommon kind of pulmonary hypertension which is which is lumped into the world health
both health World Health Organization Group one where what we call targeted
therapies are indicated. With those we started in late 90s with IV therapy and
now we have about 14 plus medications FDA approved which are approved for
treating those with that very specific condition. And those therapies have not
only improved quality of life but also improved survival in those patients from
months to years. I have a few patients who are what we call they
are veteran of pulmonary hypertension. They have survived and they
survived with these medications and as we treat we have two goals one improve
quality of life and also determine their risk of dying or risk of getting worse
over period of time. So, we reevaluate these patients very common, very
frequently and then based on the risk, if the risk is or disease is getting worse, we
escalate therapy based on their risk. If risk is getting better, then we can
maintain the same therapy and the theme is to go aggressive from day one. If we treat aggressively, the disease severity can get better quicker, there’s
a lesser strain on the heart and patients can live longer with better quality of life. We have a viewer with a question this is from
Dina Winder, she says is there a hospital in Arkansas that does
operations for pulmonary hypertension? So, the answer is right now there is one
condition in which a true operation is required to treat a certain
type of pulmonary hypertension which is a pulmonary hypertension from chronic
shoveling of clots into lungs. We have only few centers in the whole
United States who are experts in doing that operation. Basically the
operation entails opening the chest and taking all the clots out of the lung and
even from Arkansas we send those patients over those specific specialized
centers so that they have best outcome. Other than that one condition,
there not many operative or surgical therapies which are indicated
for pulmonary hypertension treatment. So, we have successfully done a few procedures
to improve quality of life but when it comes down to taking those clots out,
those patients are sent to those specific centers to have their surgeries
done. Pamela Lambert is watching tonight she wants to know is
there a certain age that people are most likely to be diagnosed with this? There’s
a great question. Based on the different types of pulmonary hypertension that
age can vary, but more commonly this is the age
of from between 35 to 65 and 75 is where this disease spreads into just like most
other conditions. But based on again the risk factors and what category the
patient can fall in that is determined. For example, a young woman with
history of lupus is at high risk of developing pulmonary hypertension at an early
age in 20s and 30s. On the other hand, a patient with heart and lung conditions
such as COPD asthma patient with heart failure they are they are more prone to
develop permeable tension at a later age in their 50s and 60s. So, the
determination of age is based on the risk factors and underlying condition
which can put them at high risk of developing pulmonary hypertension. Talk a little bit more
about treatment options. You’ve touched on it some and how those options have
changed over the years. So, we have come from an era of late 90s where we had one
IV therapy as a treatment for pulmonary hypertension – now where we have about
14 plus therapies in the pill forms and in IV forms. Based on the
the severity of the pulmonary hypertension and the risk of dying from pulmonary hypertension we ascertain what strategy will be the
best and how many of those medications will be used to improve the quality of
life. So, in 2018 the latest symposium on from WHO was done in Nice about
pulmonary hypertension and now the recommendation is that if patient is
diagnosed with at least a moderate form of pulmonary hypertension to go as
aggressive as possible with more than one medication and and hit it hard in
the beginning. So, bring the lung pressures down as much as we can with
the combination of medications based on the severity and then evaluate it more
frequently down the road and see how the pressures are. If the pressures are
coming down they stay at the course. If they are not coming down, they’re going
higher, then we keep on adding medications until those pressures are
are down enough. Now, based on the risk. If patient is high risk with low
heart output, or if they have severe symptoms then from get-go we
start with IV medications. Now when we start those IV medications, those
medications are supposed to be running from infusion port or a PICC
line or an intervein catheter that runs 24/7. That requires some specialized
teaching, specialized drug delivery and we have a few patients in our community
who are already on those medications and they are doing really well. What is their
quality of life like on these medications do they have an effect on
them? It’s a great question. So, the quality of life before starting
therapy is really bad. So, these are the patients who who can’t even walk
from their bed to the bathroom. They get short of breath and once we start
them on therapy they go back to almost normal life. Back to work, back to
shopping, back to Christmas shopping, back to being with their family. So, it
produces a dramatic difference in the quality of life. Yes the trade-off is now
they have to take care of an IV line or they have to be responsible for changing the
the cartridges that come with the IV line but the gain is their impressive
quality of life that could be improved dramatically with his medication.
We talked about the medications, the IV’s is there any sort of lifestyle changes
that people could make to improve this condition? Yes, so the risk factor
modification or risk factor stratification is one of the key
things than any disease prevention and we as healthcare providers, we advocate
that patients take care of their own health before it gets too late. For
example, if someone has a history of or risk factors for COPD, smoking should be
completely stopped. Patients with sleep apnea, they should make sure
that they are evaluated and treated for sleep apnea. Patients who have conditions
which can lead to congestive heart failure, they should be very well
identified and treated. So, taking care of risk factors can be the first step to
prevent the disease and if it gets worse then of course it can be treated. We have
several questions, people wanting you to go over the common therapies for the
different stages again. So, let’s talk about the categories where those
specialized medication therapies are indicated and that is actually the
smaller group of patients. The larger group of patients are there in all ages we
used to call it a secondary pulmonary hypertension where some other
disease was causing that. But, now that terminology has been thrown out of the
window. We have now different conditions for example patients with hepatitis C or
patients with cirrhosis can have pulmonary hypertension but if no other
cause is identified we lump those patients into an idiopathic or unknown
etiology of pulmonary hypertension or patients with who have heritable pulmonary hypertension,
patients with drug-induced pulmonary hypertention — more commonly amphetamines and
methamphetamines can lead to pulmonary hypertension as well. Now when we define by heart
catheterization that those patients will fit in the category of treatable pulmonary hypertension then
we start them, based on their severity, and how high the pressures are, we target
with one two or three different therapies. There are three main pathways
of pulmonary hypertension or treating pulmonary arterial hypertension which is specific targeted
area and those three pathways are different and hitting different
different part of the circulation. And those are more enzyme and receptor based
pathways and we hit or try to hit at least two in the beginning and if the
disease is in severe range we often start with actually a combination of
three therapies at the same time and if the heart output is too low then we
start with a combination of two pill forms and one IV form. I have a patient
at this time in the hospital who has was undiagnosed with severe pulmonary hypertension for a very long time and today we started on a
combination therapy with dual or oral tablets and then an IV form as well. We
have another viewer who’s asking you a question tonight and Suzanne Hensley Evans asks if
you have immediate family history of pulmonary hypertension, how likely are children to have it? It’s
a great question. Over the last five years there’s a huge focus on
diagnosing congenital or or heritable pulmonary hypertension. If a
patient’s family member has a diagnosis of pulmonary arterial hypertension
especially females, mother’s, sister, cousins first-degree relatives in them
there’s a high risk of developing pulmonary arterial hypertension in that
cohort and there are a few pathways that we have identified and certain
patients we can offer genetic counseling and genetic testing to define if certain
gene is modified which can lead to pulmonary arterial hypertension. How do
you work with patients as they learn to live with this condition and it become
their new normal? So, because this disease is a very
advanced specific disease we have developed a program at CHI St. Vincent
which is specific to pulmonary hypertension and that includes of
course a physician but also we have a pulmonary hypertension coordinator and nurses.
We have a pharmacist and a dietitian and we have a whole team that takes care of
this patient. So it’s not just one stop shop. It’s not just one person treatment.
In one stop the patient gets to see all these people because we have to make
changes in their diet we have to make changes in their treatment study we have
to make changes in their overall rehabilitation programs so all these
factors come into play and we interact with with one patient as
a team and over time that patient becomes our family life. You know and
that is one of the biggest game that we we get from seeing these
patients that these patients become part of us as a team and we work together. We
define goals. We define short-term goals and long-term goals and once we
define what will be the treatment strategy to reach those goals. Those are monthly goals. There are some quarterly goals and there’s some yearly
goals and working together most of time to achieve those goals. I understand that
for a long time patients would have to maybe even travel out of state to be
treated for this. How has that changed? So, until you know we started this program
at CHI St. Vincent, a lot of these patients that required advanced therapies, especially
when they required IV therapies, they had to travel out of state to Texas
Tennessee or Kansas or Missouri or Oklahoma. These patients were
traveling anywhere from between three to six hours to go to those centers to get
the treatment and there was of course a big strain on their traveling on their
health and being that sick they have to travel for that long. But now those
patients are coming here to our Center and there are a lot of patients who transferred
their care from from those centers to us and we taking care of them
in Little Rock. So, we are very proud, happy and actually blessed to have this
this program going on CHI St. Vincent, so we can offer not only the diagnostic
part of it but most importantly the treatment part of it. Short of maybe
one or two advanced surgeries which are very advanced surgeries other than that
we have the whole armamentarium of treatments that we can offer in Little Rock. What is
the life expectancy for someone with pulmonary hypertension and how important
is early detection in all of this. That is I think one of the key things to
understand and there’s a great question to know. Earlier the diagnosis is, the longer longer
the life expectancy. So, if someone comes in with a with a good
functional status and is the disease is at an early stage if it is started early
that the life expectancy can be longer. Of course
the life expectancy of a pulmonary hypertension patient is not like a normal
patient without pulmonary hypertension, yet if we can diagnose and stabilize the disease the
the life expectancy and quality of life can get significantly improved. But, if
the disease is diagnosed in later stage and it is already way far advanced we
can improve quality of life but then we have the use advanced therapies in the
form of IV medications to improve survival and we can gain two three or
four years or maybe even longer. There’s some patients who are living on IV therapy
for over ten years with those. So, again it all depends on how aggressively it is
diagnosed, detected and then treated. So, aggressively to improve those years and
add as many years as possible. It’s got to be rewarding as a physician
to see someone struggling and go through some of these therapies
to have such a better quality of life after they’ve seen you. Of course I think
that is the gain of our of our daily work. We get to meet these patients and
we have not just I, but our team has made phenomenal friends in the form of
patients and we are actually more blessed that we have a very robust
and very aggressive patient groups in in Little Rock and Arkansas. Our Central
Arkansas group is led by a patient who who has pulmonary hypertension and she’s
a veteran. She’s been leading this group for for a few years and has been
one of the key members in not only disease detection but also advocacy and
in our own government and those patients did meet quarterly. They
meet. They get together. They have lunch and I attend some of the meetings and we
sit down eat lunch and have informal discussions about the disease. How to
live with pulmonary hypertension, how to live with a disease that is such entailing and is
aggressive and I see these patients coming in with their oxygen tank, with
their oxygen on still they come there, talk get together and actually have a good
time and that is what gets us going every day. Those patients were not
able to walk before now they can actually come out not only meet each
other but also go out with their families. If there are people who
are watching tonight and they have a family history of this
or they’re a part of any of those risk factors and they have some of those
symptoms that we talked about earlier what do you encourage them to do?
So the key thing is to discuss this with your physician. If you have symptoms of
shortness of breath, which are not explained by any other condition
otherwise, you should ask your physician do I have pulmonary hypertension or not and the
simple tests that can be done to at least estimate or screen for pulmonary hypertension is to have a cardiac or
a cardiac or heart ultrasound known as echocardiogram. Echocardiogram can give
us a lot of ideas about or geometry of the heart–how high the heart pressures
can be, if the heart function is low or high or is it a stiff heart and once we
have those ideas we can easily estimate if this patient may or may not have pulmonary hypertension. If the pressures are high on echocardiogram that is where we get
more aggressive and start further testing. Dr. Muhammad Waqas thanks
for being with us tonight. We learned a lot of great information
with you and we appreciate it. Thank you for having me. All right and if you would
like to learn more about pulmonary hypertension, heart attack awareness, the latest treatments or heart
healthy tips you can go to CHIStVincent.com/heart and if you
missed any part of tonight’s web stream you can catch it anytime right here on
the KATV Facebook page. Again, thanks for being with us tonight have a great night.